Form Iv-18 - U.s. Medical Questionnaire printable pdf download

Form Iv-18 - U.s. Medical Questionnaire

U.S. MEDICAL QUESTIONNAIRE

(MUST be completed and signed by applicant prior to medical appointment)

CASE NUMBER:

VISA CATEGORY:

NAME:

(Last)

(First)

(Middle)

DATE OF BIRTH:

AGE:

GENDER: male

female

BIRTHPLACE: (City/Country)

PRESENT COUNTRY OF RESIDENCE:

PRIOR COUNTRY:

NATIONALITY:

OCCUPATION:

CURRENT ADDRESS:

TEL:

EMAIL ADDRESS:

INTENDED U.S. ADDRESS:

HEIGHT (in centimetres):

WEIGHT (in kilos):

YES

Have you ever been hospitalized (including psychiatric admission)?

Have you been investigated or treated for any major illnesses?

Have you ever had treatment or investigations for TB or been in

contact with anyone that has TB?

Have you ever had any kidney or liver disease?

Have you ever had any mental disorder or depression?

Have you ever used drugs?

Have you ever had an addiction to or abused alcohol?

Have you had any form of treatment or investigations for alcohol

or drug abuse?

Have you ever caused deliberate injury to yourself or others?

Have you ever been arrested, convicted or received a warning for

any drug or alcohol offense (including driving) anywhere in the

world?

Do you take any medication? (Please list all medications on a

separate sheet)

Have you ever had a previous medical for immigration purposes?

Are you pregnant?

If the answer is yes, please provide evidence of pregnancy/copy of pregnancy test result.

Date of last period:

Expected delivery date:

DATE:+

SIGNATURE:

If you have answered YES to any of the above, please use a separate sheet to give further details.

IV-18

May 2017

Form Iv-18 - U.s. Medical Questionnaire

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